Now Arriving Ahead of Schedule: The Future of On-Demand Medicine, Part 1

Running an urgent care platform was already getting complicated before the arrival of the Covid-19 pandemic.  By this past March it looked as if the end of the urgent care world was upon us.  Patient visits came to a halt for six weeks or more.  Those who jumped on the testing bandwagon managed to kick back into gear.  But this may be a short-lived salve for something more dramatic coming down the road.

By the middle of next year, Merchant Medicine believes we could see a noticeable shift in consumer behavior around on-demand medicine. The various players that participate in this space – primary care, urgent care, retail clinics and virtual medicine – are in for what could be the start of a major battle for the hearts and minds of a new generation of healthcare consumers.  And the downstream impact on health systems’ ability to build relationships with new patients will be felt for perhaps decades.

The curious part of all of this is that the pandemic is not the cause of the shift; it is acting as an accelerant to a situation that was smoldering already.  In this article, we will look at how the pandemic added fuel to the fire, as well as how institutional conservatism also contributed.  Technology and demographics most certainly are added components, but these are the topics for next month’s blog.

PANDEMIC AS ACCELERANT

How did the pandemic represent such a rich fertile ground for change in the healthcare space? As Covid-19 arrived in full force in March 2020, huge shifts in the supply and demand of patient care took place.  In many ways, redirecting imaging away from multispecialty centers, separating respiratory illnesses, drive-up triage and Covid-19 testing became the proving ground for how quickly provider groups could pivot.  Some pivoted in near seamless fashion.  For most large health systems, it was not so easy.

Nimbler operators not only offered testing during a stressful and unpredictable moment, they also leveraged that moment to create a positive experience to a new set of customers who were being turned away by their medical home.

Righttime Medical Care, a 19-clinic urgent care network in the MidAtlantic region, is a good case study.  Robert Graw, M.D., founder, CEO and a practicing pediatrician, started a daily 6:30 a.m. Covid-19 huddle in February.  This was in addition to the regular clinical and operational daily leadership huddles Righttime had been holding for years.  The new Covid-19 huddle included as many as 150 people not only from the Righttime leadership team but also key members of the community, including state and county governments, local hospitals, school districts and other members of the provider community.  They looked at infection numbers, hospital admissions, regional provider capacities and the statistics nationally and internationally.  This huddle was key to anticipating the coming surge of infections and the many hurdles Righttime would have to navigate.  After the 6:30 huddle, the Righttime leadership team took what they learned and addressed operational issues: PPE, personnel, patient volume and expenses.

“By mid-March things died abruptly,” said Graw.  “Schools closed. Employees were sent home. Our numbers dropped to two thirds of what they were before. We closed one center that was affiliated with the university, which had shut down in-person classes.  At other locations we adjusted hours and staffing to complement what was being done by the local counties and hospitals.”

By engaging with the community early on, particularly state and county leaders in Maryland, the Righttime leadership team recognized they could become a critical link in the community in providing real medical care, not just triaging patients and sending them elsewhere.  They expanded their telemedicine capabilities to provide more support to patients trying to decide how best to get care, and in following them after they received care at the Righttime centers.  They opened their urgent care locations as testing sites in April, each with separate entrances and hours.  Righttime’s decision years ago to design their centers without waiting rooms turned out to be hugely advantageous.  Instead of the traditional waiting room at the front of the centers, each center has a perimeter with seating to spread out patients into their own small waiting areas or “cubbies.”

“Patients quickly perceived this as a safe place to obtain care with or without COVID,” says Graw.  “Get in and get out without a big wait.”

By early June people began to return and Righttime’s numbers now far exceed the numbers from this time last year.

TOUGH DECISIONS

But while Covid-19 was viewed as an opportunity to be nimble for some operators, it also demonstrated the complications faced by larger traditional medical groups and health systems.  Not only did patients stop going to see their regular doctor, many doctors and clinics made the first move by closing their doors or making it very inconvenient for their patients.  Most were victims of institutional decisions to protect workers and preserve PPE.

“It’s interesting how paralyzed the primary care community became,” says Graw.  “As a participant in the pediatric community, I was on calls with insurance carriers and state leaders, as well as with primary care providers.  Primary care offices are still hesitant to put the right things in place.”

Many institutions, understandably so, had as much fear for their employees interacting with patients as patients had in coming to a clinic.  These fears reached such an extent during the pandemic that many practices are now finding it difficult to recover patients lost to new providers and new approaches that made patients feel safe.

DISCONNECT WITH CONSUMERS

But there are also potential pre-pandemic dynamics that are finally starting to manifest as permanent structural changes.  The first is virtual medicine, which will be covered next month.

The second is the disconnect between traditional health systems and consumers.  There are two reasons this debate may be amplified over the coming year.

First, there is now a consistent percentage of individuals who do not have a strong primary care relationship.  That number is around 40 percent, according to Luke Peterson, principal at Health System Advisors, the parent company of Merchant Medicine. 

But more alarming is the accelerating trend of consumers making healthcare decisions without traditional primary care guidance.  This will this have a huge impact on how health systems connect with new patients in their communities.

“The thing that strikes me the most is that health systems don’t understand the sophistication of their consumers,” says Peterson “Health systems don’t give consumers enough credit for their knowledge and capacity to acquire knowledge rapidly using their own resources.”

That notion, that health systems are underestimating the sophistication of consumers when it comes to healthcare decisions, is unnervingly similar to other recent examples of major industries or institutions missing trends that ultimately cost market share, or in some cases caused businesses to close.

For example, huge media companies missed the impact of social media on their role as a neutral purveyor of news, the trusted middleman who sorts out fact from fiction.

And social media companies themselves completely underestimated how their platforms would be manipulated by various groups with nefarious motives.  Those social media companies now find themselves having to play the same trusted middleman role that traditional media has played.

In both cases, Zeynep Tufekci (pronounced ZAY-nep too-FEK-chee) saw this coming.  She is a sociologist who wrote the book Twitter and Tear Gas: How Social Media Changed Protest Forever.  She was also the subject of a recent New York Times profile by Ben Smith that highlighted her uncanny ability to make the right call when so many other “experts” had gotten things wrong. 

Tufekci emerged on the international health care stage when the U.S. Centers for Disease Control earlier this year recommended that the public should not wear masks.  She came out against that recommendation in a March 1 tweetstorm before expanding on her criticism in a March 17 Op-Ed article for The New York Times.  In the end, she turned out to be right and the worldwide epidemiological community now agrees that face masks should be worn.

One commonality of Tufekci’s thinking is that we should trust that the larger community is more capable than large institutions give them credit for.  In Ben Smith’s profile of Tufekchi he says, “Now I find myself wondering: What is she right about now? And what are the rest of us wrong about?”

WHAT’S NEXT?

Are we about to face a revolution in ambulatory healthcare?  While large health systems struggle to sort out their many investment priorities, private equity groups have spent the last decade investing not only in urgent care, but other specialties and service lines like ambulatory surgery, orthopedics, ophthalmology, physical therapy, dermatology, dentistry and many others.

Tim Wheeler is a vice president at Chicago-based BPOC, one of the private equity firms seeking to invest in multispecialty services lines.  He says Covid-19 has exposed a major weakness for health systems, whose large on-campus multispecialty centers have until now been the cash cow.

“Those who have just built or are building ‘Taj Mahal’ multispecialty centers as the front door to their health system have to be losing a lot of sleep,” says Wheeler.  “I don’t think we will go back to the big crowded waiting rooms in large centralized facilities.  Patients will be looking for flexibility and attention to detail around keeping them safe.  The smaller, community-based centers without traditional waiting rooms are likely the future of non-emergent care.”

Time will tell whether these large brick and mortar centers will become dinosaurs.  Or whether multispecialty centers symbolically represent a larger problem for health systems: inflexibility in relating to consumers the way they are accustomed to being treated in most other retail or online interactions.

“Many hospital systems are still demanding that individuals relate to them on the hospital’s terms,” says Peterson of Health System Advisors. “The next generation of healthcare consumers wants to relate to health systems on their own terms.”

In Part 2 next month, we’ll look at the demographics of that next generation and the technologies that are embedded in their lifestyles.